PEDIATRIC

ORTHOPEDICS
Joyce Coffey RN MSN/ED
City College of San Francisco
NUR 54 Nursing of Children
Fall 2013

Learning Objectives

In this lecture students will learn:

Basic anatomy and physiology of the

musculoskeletal system
Selected musculoskeletal disorders in the
pediatric population
Common diagnostic tests for
musculoskeletal problems
Orthopedic treatments and procedures
Nursing care for children with alterations in
musculoskeletal function

Skeleton of Newborn

Gaps between bones indicate

cartilage, which will develop into
bone tissue as the child ages

Stages of Long Bone Growth

Process of
cartilage
calcifying and
becoming mature
and compact
bone

Key Concepts

Bone formation is incomplete at birth

Bone growth and ossification continues
throughout childhood
Treatment depends on cause

Malformation
Infection
Injury

DEFECTS IN PHYSICAL DEVELOPMENT

Causes of congenital malformations

(anomalies)

Genetic factors
Environmental factors

CRANIAL
DEFORMITIES

MICROCEPHALY

Definition

Reflects a small brain

Autosomal recessive or chromosomal
abnormality

Microcephaly

Primary

Secondary

Intrauterine exposure to toxins (weeks 4 to 20)

Third-trimester exposure
Perinatal exposure
Exposure in early infancy

Effects

Mild hyperkinesis, mild motor impairment

Decerebration, complete unresponsiveness
Autistic behavior

CRANIOSTENOSIS

Premature closure
of 1 or more
cranial sutures

Therapeutic Management

Surgical excision of bone (strip

craniectomy)

Along or parallel to suture

Releases fused suture
Directs new growth

Before 6 mo old

Best cosmetic and neurodevelopmental

results
Least amt of brain damage

Craniostenosis
Before tx

After tx

PLAGIOCEPHALY

Skull
progressively
flattened
Not associated
with brain
malformation
Treatment

Helmets,
bands( elastic
bands to make it
more

Plagiocephaly

Cranio Helmets after Release of Ossified

Sutures

SKELETAL DEFECTS

DEVELOPMENTAL DYSPLASIA
of the HIP (DDH)

Formerly called congenital hip

dysplasia and congenital dislocation of
the hip
Incidence 1-10/1000 live births
More common in females (60%)
More common in Caucasians than any
other group

Displaced Hips

Etiology of DDH

Physiologic
Mechanical
Genetic
Classifications

Acetabular
Subluxation
Dislocation

Configuration and Relationship of

Structures

Clinical Manifestations of
DDH

Positive Ortolani test

Audible

click when abducting and externally

rotating hip

Barlow maneuver
Shortening of limb (femur) on affected side
Asymmetric gluteal, popliteal, and thigh
folds
Broadening of the perineum
Limited abduction of hip on affected side
Waddling gait and lordosis

Clinical Manifestations
(contd)

In older infant and child

Affected leg shorter than the other

Telescoping or piston mobility of joint
Positive trendelenburg sign
Greater trochanter is prominent and
appears above a line from anterior superior
iliac spine to tuberosity of ischium
Marked lordosis if bilateral dislocations
Waddling gait if bilateral dislocations

Assessment of DDH

Assess for Ortolani Click

Therapeutic Management of
DDH

Directed toward enlarging and deepening acetabulum

Place

head of femur within acetabulum

Apply constant pressure
Legs slightly flexed and abducted

Splinting
Spica cast
Pavlik harness

Surgical

intervention

ORIF with casting

Age variations
Newborn

to 6 months
6 to 18 months
Older child

Spica cast

Nursing Considerations for

DDH

Limit risk for hypostatic pneumonia( not

moving not moving lung)
Maintain skin integrity
Prevent constipation( they kcik their legs
and moving to increase peristatlsis)
Encourage nutritious foods
Move and position safely when in spica cast
Meet emotional needs
Provide parents with help and support

CONGENITAL CLUBFOOT

Congenital Clubfoot

Bone deformity and malposition of foot

Talipes equinovarus (TEV)( most common we see)

Soft tissue contracture

Foot twisted out of alignment
May be misshaped
Toes pointed downward and inward

Incidence 1-2 per 1000 live births

More common in males
Bilateral clubfeet in 50% of cases
Familial tendency( does tend to run in family)

Clinical Findings

Deformity apparent at birth

Classification

Rigid or flexible
Mild (positional)
Syndromic (associated with other
congenital abnormalities)
Congenital
Wide

range of prognosis
Usually requires surgical intervention

Therapeutic Interventions

Started during newborn period

Non-surgical

Delay causes abnormal development of leg

muscles and bones with shortening of tendons
Passive exercise
Serial casting
Orthotics

Surgical

Tight ligaments released

Tendons lengthened

Orthotic for Club Foot after

Casting

Nursing Considerations

Assess and educate parents

Monitor CMS and skin( consider tissue

breakdown)
Monitor cast and special orthopedic shoes
Follow-up care( when the family has to
come back every week)

THE CHILD AND TRAUMA

Epidemiology of Trauma

Trauma is leading cause of death in

children older than 1 year
Aspects of injury are affected by the
developmental stage of child

Trauma

Types

Nonintentional injury
Child abuse injury( multiple bruises does
the clinical picture match)

Dependant on:

Age
Developmental level
Preventative measures

THE IMMOBILIZED CHILD

Immobilization was once thought to be

restorative from illness and injury
We know now that immobilization has
serious consequences

Physical
Social
Psychologic

Immobilized Child

Physiologic Effects of Immobilization

Physiologic Effects of Immobility

Muscular system

Decreased muscle strength and endurance

Atrophy
Loss of joint mobility

Skeletal system

Bone demineralization
Negative calcium balance

Physiologic Effects of Immobility

Metabolism

Decreased metabolic rate( not moving,

decrease nitrogen balance)
Negative nitrogen balance
Hypercalcemia
Decreased production of stress hormones

Physiologic Effects of
Immobility

Cardiovascular system

Decreased efficiency of orthostatic

neurovascular reflexes
Diminished vasopressor mechanism( you
are not using it )
Altered distribution of blood volume( its
going to pool on whatever position is
depended
Venous stasis
Dependent edema

Physiologic Effects of
Immobility

Respiratory system

Decreased need for oxygen

Diminished vital capacity
Poor abdominal tone and distention
Mechanical or biochemical secretion
retention
Loss of respiratory muscle strength

Physiologic Effects of
Immobility

GI system

Distention caused by poor abdominal

muscle tone( not using it not breathing ,
nost standing , moving our legs)
Difficulty feeding in prone position
Gravitation effect on feces
Anorexia( no nutrition)

Physiologic Effects of
Immobility

Integumentary system

Decreased circulation and pressure leading

to decreased healing capacity

Urinary system

Alteration of gravitational force

Difficulty voiding in supine position
Urinary retention
Impaired ureteral peristalsis

Physiologic Effects of Immobility

Loss of innervation

If nerve tissue is damaged by pressure

If circulation to nerve tissue is interrupted
Effects of improper positioning

Sensory and perceptual

deprivation( stimulating the growth and
development)

Tissue Breakdown

Psychologic Effects of
Immobility

Diminished environmental stimuli

Altered perception of self and
environment
Increased feelings of frustration,
helplessness, anxiety
Depression, anger, aggressive behavior
Developmental regression

Effect on Families

Extended periods of immobilization

Logistical management of sick child

Need for family support and home care
assistance
Coping

skills

Mobilization Devices
Orthotics

Knee-Ankle-Foot Orthotic

Mobilization Devices
Thoracolumbosacral
Orthotic

Rear-Rolling Walker

Mobilization Devices
Crutches

Wheelchair

Mobilization Devices
Bike Walker

Gait Walker with

Suspension Belts

EPIPHYSEAL INJURIES

Epiphysis

Growth end of long bones

Growing

cartilage to that hard bone

Growth plate located in the epiphysis

Weakest point of long bones ( where the growing is
meeting the osfied bone)

Frequent site of damage during trauma

May affect future bone growth
Treatment may include open reduction and
internal fixation to prevent growth disturbances

FRACTURES

Common injury in children

Clavicle most frequently broken bone in
child, especially younger than age 10
School agebike, sports injuries
Methods of treatment different in
pediatrics than in older adult population

Types of Fractures

Compound or open

Complicated

bone fragments have damaged other organs or

tissues

Comminuted

fractured bone protrudes through the skin

small fragments of bone are broken from the

fractured shaft and lie in surrounding tissue

Greenstick( child abuse)

compressed side of bone bends, but tension side of

bone breaks, causing incomplete fracture

Clinical Manifestations of
Fracture

Generalized swelling
Pain or tenderness
Diminished functional use (decreased
movement)
Deformity of bone
Ecchymosis
Guarding
Severe muscular rigidity, crepitus

Diagnostic Evaluation

Visual ( sometimes you can see it , ifyou

cant see it xray)
X-ray is the most useful diagnostic tool

Immediate Interventions

Immobilize
Assess circulation
Apply cool/cold compress
Elevate limb ( keep in alignment)
Sterile/clean dressing over open wound

Therapeutic Interventions

Splints( non invasive, bc of swelling)

Casts

Surgery

Hard or soft
Promote bone alignment
Prevent further damage
Internal fixation (ORIF)
External fixation

Traction

External Fixation

Ilizarov external
fixator

The induction of new

bone between bone
surfaces that are
pulled apart in a
gradual, controlled
manner
Permits limb
lengthening by manual
distraction
Stimulates new bone
formation

Bone Healing and

Remodeling

Typically rapid healing in children

Neonatal period2 to 3 weeks
Early childhood4 weeks
Later childhood6 to 8 weeks
Adolescence8 to 12 weeks

Nursing Considerations

Assessment of the 5 Ps

Pain and point of tenderness

Pallor
Paresthesia distal to fx
Pulselessness distal to fx site
Paralysis; lack of movement distal to fx site
(late and ominous sign)

Cause of injury

Nursing Interventions

Use age appropriate pain rating scales

Monitor neurovascular status of distal extremity

Distraction and entertainment

Monitor operative site

Avoid using affected side for vital signs

Allow cast to dry by exposing to air

Provide age appropriate activity

Medicate appropriately

Internal and external fixation

Maintain functional alignment with supportive

devices

Types of Casts

Spica Cast with Hip

Abductor

Young Children Come to Regard Casts as

Part of Their Body

THE CHILD in TRACTION

Tractionextended pulling force may be

used to

Provide rest for an extremity

Help prevent or improve contracture
deformity
Correct a deformity
Treat a dislocation
Allow position and alignment
Provide immobilization
Reduce muscle spasms (rare in children)

Traction- Essential
Components

Tractionforward force produced by

attaching weight to distal bone fragment

Countertractionbackward force
provided by body weight

Adjust by adding or subtracting weights

Increase by elevating foot of bed

Frictional forceprovided by patients

contact with the bed

Application of Traction for Maintaining

Equilibrium

Types of Traction

Manual traction

Skin traction

applied to the body part by the hand placed

distally to the fracture site
pulling mechanisms are attached to the skin
with adhesive material or elastic bandage

Skeletal traction

applied directly to skeletal structure by pin,

wire, or tongs Inserted into or through the
diameter of the bone distal to the fracture

Child in Skeletal Traction

Cervical Traction

Crutchfield or Barton tongs

Inserted through burr holes in skull with
weights attached to the hyperextended
head
As neck muscles fatigue, vertebral
bodies gradually separate so the spinal
cord is no longer pinched between
vertebrae
Halo traction can be applied in some
cases

TRAUMATIC INJURY

Soft tissue injuryinjuries to muscles,

ligaments, and tendons

Sports injuries
Mishaps during play

Types of Injuries

Acute overload injuries

Overuse syndromes( kids w/ yr round
sports)

Repetitive microtrauma
Inflammation of the involved structure
Complaint of pain, tenderness, swelling,
disability
Examplestennis elbow, Osgood-Schlatter
disease

Types of Injuries

Contusions
Dislocations
Sprains
Strains
Stress Fractures

Sites of Injuries to Bones, Joints, and

Tissues

Therapeutic Management of Soft Tissue

Injuries

RICE

Rest the injured part

Ice immediately (max 30 minutes at a time)
Compression with wet elastic bandage
Elevation of the extremity

ICES- Ice, Compression, Elevation,

Support
Immobilization and support (casts or
splints as appropriate to injury)

Correct and Incorrect Methods for

Elevating a Lower Extremity

MUSCULOSKELETAL COMPLICATIONS

Circulatory impairment
Nerve compression syndromes
Compartment syndromes
Volkmann contracture
Epiphyseal damage
Nonunion/malunion
Infection
Kidney stones
Pulmonary emboli

COMPARTMENT SYNDROME

Pressure within the muscles builds to

dangerous levels (from swelling or
bleeding)

Decreases blood flow

Prevents nourishment and oxygen from
reaching nerve and muscle cells
Causes cell damage and death

Acute or chronic
More painful than would be expected

Not relieved by pain meds

Compartment Syndrome

Fasciotomy

OSTEOMYELITIS

Bacteria infection of bone

Direct infection (injury, hardware
insertion)
Hematogenous Osteomyelitis common in
children
Bacterial infection from one site of the
body travels through blood stream to
bone

Osteomyelitis
Femur

Calcaneus

Clinical Manifestations of Osteomyelitis

Localized Pain
Swelling at site
Warm at site
Redness at site
Pain upon weight bearing

Osteomyelitis Diagnosis

Signs and symptoms begin abruptly;

resemble symptoms of arthritis and
leukemia
Marked leukocytosis
Bone cultures obtained from biopsy or
aspirate
Early x-rays may appear normal
Bone scans for diagnosis

Therapeutic Management of
Osteomyelitis

May have subacute presentation with

walled-off abscess rather than a
spreading infection
Prompt, vigorous IV antibiotics for
extended period (3 to 4 weeks or up to
several months)
Monitor hematologic, renal, hepatic
responses to treatment

Nursing Considerations

Complete bed rest and immobility of

limb
Pain management concerns
Long-term IV access (for antibiotic
administration)
Nutritional considerations
Long-term hospitalization/therapy
Psychosocial needs

MUSCULOSKELETAL
DYSFUNCTION

LEGG-CALV-PERTHES
DISEASE

Avascular necrosis of femoral head

Self-limited
Idiopathic
Affects children ages 3 to 12
More common in males ages 4 to 8
10-15% bilateral hip involvement
Most have delayed bone age

Legg-Calv-Perthes Disease

Legg-Calv-Perthes Disease

Pathophysiologycause unknown but

involves disturbed circulation to the
femoral head with ischemic aseptic
necrosis
After resolving, may have normal
femoral head or may have severe
alteration

Legg-Calv-Perthes Disease

Prognosis

Self-limited disease
Outcome has wide variations due to
multiple factors

Nursing considerations

Identification of affected children and

referral
Teaching care and management
Compliance issues with child/family

Therapeutic Management

Treatment goalkeep head of femur in

acetabulum
Containment with various appliances
and devices
Rest, no weight bearing initially
Surgery in some cases
Home traction in some cases
May take up to 4 years of therapy

SCOLIOSIS

The most common spinal deformity

Complex spinal deformity in three planes

May be congenital or develop during childhood

Lordosis

Lateral curvature
Spinal rotation causing rib asymmetry
Thoracic hypokyphosis

Accentuation of the cervical or lumbar curvature beyond

physiologic limits (swayback)

Kyphosis

Abnormally increased convex angulation in the curvature of

the thoracic spine (round shoulders or hunched shoulders)

Scoliosis (contd)

Multiple potential causes; most cases

idiopathic
Generally becomes noticeable after
preadolescent growth spurt
May have complaint of ill-fitting
clothes
School screening controversial

Diagnostic Evaluation

Standing radiographs to determine

degree of curvature
Asymmetry

shoulder height
scapular
flank shape
hip height

Often have a primary curve and a

compensatory curve to align head with
gluteal cleft

Clinical Manifestations

Insidious onset

May have history of limp

Soreness or stiffness
Limited ROM
Vague history of trauma

Pain and limp most evident on arising

and at end of activity
Diagnosed by x-ray

Therapeutic Management

Team approach to treatment

Bracing

Must be worn 23 hrs/day

Exercise
Surgical intervention for severe
curvature (various systems of
instrumentation and fusion)

Harrington, Dwyer, Zielke, Luque, CotrelDubousset, Isola, TSRH (Texas Scottish Rite
Hospital), and Moss Miami

TLSO Braces

Success with Bracing

Surgical repair

Nursing Interventions

Maintain spinal alignment per protocol

Provide care when wearing brace

Examine skin surfaces where contact with brace

Implement corrective action for skin breakdown
Help select appropriate apparel to wear over brace to
minimize altered appearance
Encourage wearing low-heeled shoes for balance

Reinforce instructions regarding plan of care

Use of appliance
Activities
Prepare for surgery when appropriate

Nursing Considerations

Concerns of body image

Concerns of prolonged treatment of
condition
Preoperative care
Postoperative care
Family issues

JUVENILE IDIOPATHIC ARTHRITIS (JIA)

Formerly called JRA (juvenile rheumatoid

arthritis)
Possible causes

Chronic autoimmune inflammatory disease

Affects joints and other tissue

1 in 1000 children
Peak ages: 1-3 years and 8-10 years
Female predominance 2:1
Often undiagnosed

JIA (contd)

Actually a heterogeneous group of

diseases

Pauciarticular onset (involves 4 joints)

Polyarticular onset (involves 5 joints)
Systemic onset (high fever, rash,
hepatosplenomegaly, pericarditis, pleuritis,
lymphadenopathy)

JIA (contd)

90% children have negative rheumatoid

factor
Symptoms may burn out and become
inactive
Chronic inflammation of synovium with
joint effusion, destruction of cartilage,
and ankylosis of joints as disease
progresses

Symptoms of JIA

Stiffness
Swelling
Loss of mobility in affected joints

Most common in morning and after

inactivity

Warm to touch, usually without

erythema
Tender to touch in some cases
Symptoms increase with stressors
Growth retardation

Diagnostic Evaluation of JIA

No definitive diagnostic tests

Elevated sedimentation rate in some
cases
Antinuclear antibodies common but not
specific for JRA
Leukocytosis during exacerbations
Diagnosis based on criteria of American
College of Rheumatology

American College of Rheumatology

Diagnostic Criteria

Age of onset younger than 16 years

One or more affected joints
Duration of arthritis more than 6 weeks
Exclusion of other forms of arthritis

Therapeutic Management of
JIA

No specific cure
Goals of therapy

Preserve function
Prevent deformities
Relieve symptoms

Iridocyclitis/uveitis

Inflammation of iris and ciliary body

Unique to JRA
Requires treatment by ophthalmologist

Pharmacology for JIA

NSAIDs (Nonsteroidal anti-inflammatory

drug)
SAARDs (Slow-acting anti-rheumatic
drug)

Used when first-line therapy (NSAIDs), fails

to control disease

Corticosteroids
Cytotoxic agents
Immunomodulators

Management of JIA

Therapy individualized to child

PT, OT
Nutrition
Exercise
Splinting devices
Pain management
Prognosis

Nursing Interventions

Emphasize medication protocol

Promote functional alignment
Encourage warm baths or warm moist
compresses
Offer nutritious diet
Promote adequate rest and sleep
Provide emotional support

THE END